key: cord-300774-5mrkmctl
authors: Hernández-Mora, Miguel Górgolas; Cabello Úbeda, Alfonso; Pérez, Laura Prieto; Álvarez, Felipe Villar; Álvarez, Beatriz Álvarez; Rodríguez Nieto, María Jesús; Acosta, Irene Carrillo; Ormaechea, Itziar Fernández; Al-Hayani, Aws Waleed Mohammed; Carballosa, Pilar; Martínez, Silvia Calpena; Ezzine, Farah; González, Marina Castellanos; Naya, Alba; de las Heras, Marta López; Rodríguez Guzmán, Marcel José; Guijarro, Ana Cordero; Lavado, Antonio Broncano; Valcayo, Alicia Macías; García, Marta Martín; Martínez, Javier Bécares; Roblas, Ricardo Fernández; Piris Pinilla, Miguel Ángel; Alen, José Fortes; Pernaute, Olga Sánchez; Bueno, Fredeswinda Romero; Frades, Sarah Heili; Romero, Germán Peces Barba
title: Compassionate Use of Tocilizumab in Severe SARS-CoV2 Pneumonia
date: 2020-10-25
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.10.045
sha: 
doc_id: 300774
cord_uid: 5mrkmctl

INTRODUCTION: Tocilizumab is an interleukin 6 receptor antagonist which has been used for the treatment of severe SARS-CoV-2 pneumonia (SSP), aiming to ameliorate the cytokine release syndrome (CRS) -induced acute respiratory distress syndrome (ARDS). However, there are no consistent data whom might benefit most from it. METHODS: We provided tocilizumab on a compassionate-use basis to patients with SSP hospitalized (excluding intensive care and intubated cases) who required oxygen support to have a saturation >93%. Primary endpoint was intubation or death after 24 hours of its administration. Patients received at least one dose of 400 mg intravenous tocilizumab during March 8-2020, through April 20-2020. RESULTS: A total of 207 patients were studied and 186 analysed. The mean age was 65 years and 68% were male. A co-existing condition was present in 68 % of cases. Death prognostic factors were older age, higher IL-6, D-dimer and high sensitivity C reactive protein (HSCRP), lower total lymphocytes and severe disease requiring higher oxygen support. The primary endpoint (intubation or death) was significantly worst (37% vs 13%, p < 0·001) in those receiving the drug when the oxygen support was high (FiO2 > 0.5%). CONCLUSIONS: Tocilizumab is well tolerated in patients with severe SARS-CoV-2 pneumonia, but it has a limited effect on the evolution of cases with high oxygen support needs.

Tocilizumab is an interleukin 6 receptor antagonist which has been used for the treatment of severe SARS-CoV-2 pneumonia (SSP), aiming to ameliorate the cytokine release syndrome (CRS) -induced acute respiratory distress syndrome (ARDS). However, there are no consistent data whom might benefit most from it.

We provided tocilizumab on a compassionate-use basis to patients with SSP hospitalized (excluding intensive care and intubated cases) who required oxygen support to have a saturation >93%. Primary endpoint was intubation or death after 24 hours of its administration. Patients received at least one dose of 400 mg intravenous tocilizumab during March 8-2020, through April 20-2020.

A total of 207 patients were studied and 186 analysed. The mean age was 65 years and 68% were male. A co-existing condition was present in 68 % of cases. Death prognostic factors were older age, higher IL-6, D-dimer and high sensitivity C reactive protein (HSCRP), lower total lymphocytes and severe disease requiring higher oxygen support. The primary endpoint (intubation or death) was significantly worst (37% vs 13%, p<0·001) in those receiving the drug when the oxygen support was high (FiO2 >0.5%).

Since December 2019 the SARS-CoV-2 pandemic has affected more than 12,5 million people worldwide and more than 560,000 fatalities have been recorded [1] at the time of writing. Patients with severe SARS-CoV-2 pneumonia (SSP) die due to poor oxygenation despite ventilatory support and different treatments including drugs with anti-viral activity, such as remdesivir, lopinavir/ritonavir, interferon beta, hydroxychloroquine; and/or anti-inflammatory drugs, such as corticosteroids, azithromycin and low molecular weight heparin amongst other [2] [3] [4] [5] .

Pathological post-mortem samples of lung and bone marrow of these patients show diffuse alveolar damage with alveolar edema, hyaline membranes and microvascular thrombosis along with extensive hemophacytosis in the bone marrow [6] . Laboratory data show high levels of ferritin, interleukin-6, C-reactive protein, LDH and D dimer, all indicative of a cytokine release syndrome (CRS) -induced ARDS [7] [8] [9] [10] derived from the viral infection.

It is believed that the severity of SARS-CoV-2 pneumonia depends not only on the viral load in lung tissue but mainly on the inflammatory response of the host. Interleukin-6 is a key factor for the activation of the cis-and trans-signaling pathways leading to the cytokine release syndrome [11, 12] . Tocilizumab (TCZ) is an interleukin 6 receptor antagonist which has been used for the treatment of rheumatoid arthritis [13] and for the treatment of chimeric antigen receptor (CAR) T cell-induced CRS in cancer patients [14] [15] [16] . Information about its use for SARS-CoV-2 pneumonia is limited [17, 18, 30, 31] and results of randomized clinical trials are still pending [19, 20] .

We present a cohort of 207 patients treated with TCZ at a single institution during the COVID-19 outbreak in Madrid with the aim to identify which clinical or laboratory factors might influence the evolution of SSP in this group of patients and to evaluate the tolerance of this drug in this clinical entity.

From 8 th of March until 19 th of April 2020 a total of 207 with severe SARS-CoV-2 pneumonia admitted to the Fundación Jiménez Díaz University Hospital in Madrid received TCZ. SSP was defined as the presence of unilateral or bilateral lung infiltrates with basal oxygen saturation below 94% in patients with confirmed positive COVID-19 RT-PCR (Viasure® SARS-CoV-2 Real Time PCR detection kit) in nasopharyngeal or throat swabs or, in the absence of microbiological confirmation, the existence of clinical (fever, cough, dyspnoea, fatigue, etc), radiological (lung infiltrates), epidemiological (close contact with documented patients) and laboratory data (lymphopenia, high levels of ferritin, high sensitivity C reactive protein (HSCRP), LDH, interleukin-6, D-dimer) suggestive of COVID-19 infection. Tocilizumab was recommended as a rescue treatment for patients not improving after the initial three days of intensive therapy including pulse steroids and low dose cyclosporine (see above) and requiring a FiO2 greater than 0.35% to achieve an oxygen saturation above 93%. A single dose of TCZ [400 mg if weight <75 kg and 600 mg if >75 kg] was given intravenously. 17 patients with very severe disease (median FiO2 1%, IQR:0·4-1) received one or two more consecutive doses if the drug was readily available. 29 patients received TCZ with FiO2 <0.35%, despite our protocol recommendation, due to their physician decision. Ten patients received TCZ when requiring high flow oxygen support (FiO2 >1) and were not included in the analysis as they were being attended at the intensive care respiratory unit, just before intubation at the intensive care unit. None of the patients included in the study were at the intensive care unit at the time of TCZ administration and none had any concomitant known acute or previous infection or contraindication for its use at the time of TCZ administration (Less than 50x10 9 platelets or less than 500 neutrophils per µL, ALT or AST 5-fold elevations, or decreased renal function).

Data on patient´s oxygen-support at admission, before and after tocilizumab administration were recorded according to the standard clinical practice. Laboratory values before TCZ administration including absolute lymphocyte counts, serum ferritin, interleukin-6, high sensitive C reactive protein, D-Dimer, serum creatinine, ALT, AST, LDH and lipid profile were available for most cases. Laboratory data after TCZ administration were obtained in the range of 2 to 5 days after, and were not available in all cases. The primary endpoint was the need for intubation or death. Eleven patients who required intubation or died within 24 hours after TCZ administration were not included in the analysis (four died and 7 were intubated) because we believed that there was not enough time to evaluate the effect of the drug as most of them were in an extremely severe condition at the time of TCZ administration, and these patients will be evaluated in another study of critical cases attended in intensive care.

All patients signed an informed consent for the compassionate use of TCZ before its administration. This study was approved by the Medical Ethics Committee of the Fundación Jiménez Díaz University Hospital. All data were collected by the investigators who performed the statistical analysis.

All patients who received at least one dose of tocilizumab between March 8, 2020 until April 20, 2020 were included in the study. Distribution normality was assessed using the Kolmogorov-Smirnov test. Normally distributed data were presented as mean (SD), nonnormally distributed data as median (IQR), and categorical variables as frequency (%). Differences between groups were analysed by Chi-square test for categorical data or one-way ANOVA for continuous data. Kaplan-Meiers curves were used for survival studies. Results are reported as point estimates and 95 percent confidence intervals. Analysis were done with SPSS software version 24.0.

In total, 207 hospitalized patients received at least one dose of 400 mg or 600 mg iv TCZ between March 8, 2020 until April 20, 2020, of whom 21 were excluded of the analysis because required high oxygen flow before TCZ administration (10 cases) or were intubated or died within the first 24 hours after TCZ administration (11 cases) leaving 186 patients for the analysis. 169 (91%) patients received one dose, 16 patients two doses and 1 patient three doses.

The main clinical characteristics of patients are summarized in Table 1 . The mean age of patients was 65 years and 68% were male. 68% of patients had a co-existing condition, high blood pressure being the most prevalent (51%). At the time of TCZ administration 114 (61%) patients required FiO2 ≥0.5% and 72 (39%) required FiO2 <0.5%. The main laboratory values before TCZ administration showed a marked elevation of ferritin, interleukin-6 and C-reactive protein, D-dimer and a low absolute lymphocyte count.

Almost all patients (168p, 90·3%) had received antiretroviral drugs (lopinavir/ritonavir) for a median duration of 3 days (IQR:1-5). Hydroxychloroquine or chloroquine sulphate had been administered to 97·8% of cases; cyclosporine to 89·2%, interferon beta-1b to 9·7% and LMWH to 96·2%. Pulse methyl-prednisolone had been given to 95·7% of cases at a dose of 250 mg/day for one to three days before TCZ. Antimicrobial agents, either doxycycline or azithromycin was given to all patients for a minimum duration of 5 days.

During a follow-up period of fifteen days 51 patients achieved the primary endpoint (intubation or death) 19 patients needed intubation (of whom 4 died) and 36 died (32 of whom were not intubated). The primary endpoint (intubation or death) was significantly different in the group receiving TCZ when the oxygen support was high (FiO2 >0.5 %) compare to those with FiO2 ≤0.5% (37% vs 13%, p<0·001) (Figure 1) ( Table  2) .

Changes in laboratory data 2 to 5 days after TCZ administration are shown in Table 3 . A statistically significant decrease in the median serum ferritin and the median HSCRP was observed. Interleukin-6 and D-dimer median serum levels increased and the median absolute lymphocyte count remained stable.

Thirty-six patients died despite TCZ treatment. The main demographic, clinical and laboratory data of patients who died and survived are shown in Table 4 . Patients who died were older (75·8 years versus 62·5, p<0·001), had any co-existing condition (89% vs 63%, p=0·003), specifically high blood pressure (69% vs 46%, p=0·12); had a higher mean interleukin-6 before and after treatment (389 vs 116, p=0.017, and 1168 vs 311, p<0·001 respectively), a higher mean HSCRP after treatment (3·5 vs 2·0, p<0·009), a lower absolute lymphocyte count before and after treatment (633 vs 803, p=0.052, and 527 vs 860, p=0·001 respectively), and a higher median D-dimer before and after treatment (8,288 vs 2,045, p=0.027, and 7832 vs 3190, p=0·027 respectively). The global survival rate of those who received TCZ was 81% (150p), and it was 94 % for those who received it when their oxygen support was with a FiO2 ≤0.5%, and 72% when it was >0.5% (p=0,000).

A total of 11 (5·9%) patients had serious adverse reactions related to TCZ reported by their treating physicians, including increased hepatic enzymes (5 cases) or bilirubin (3 cases), increased creatinine (3 cases), hyperkalaemia (1 case), and headache (1 case). Secondary acquired infections after TCZ administration were documented in 13 cases (6·3%), including fungal (Candida spp 7 cases, Aspergillus spp 2 cases) and bacterial (Pseudomonas aeruginosa 2 cases, Klebsiella pneumoniae 2 cases, Enterococcus spp 2 cases).

SARS-CoV-2 has infected more than 12,5 million people and killed more than 560,000 and, as yet, there is a lack of effective therapy for this novel disease [21] . Several antiviral drugs, such as remdesivir -an RNA polymerase nucleotide analogue -and lopinavir/ritonavir -an HIV protease inhibitor -have been tested either in a limited number of cases or in small clinical trials showing some benefits (remdesivir) [3] or none at all (lopinavir/ritonavir) [2] . However, clinical and pathological studies of SARS-CoV-2 disease indicate that a systemic cytokine storm due to macrophage activation may be the leading cause of death in the vast majority of patients, usually occurring two to four weeks after primary infection [14] [22] [23] . Therefore, immunomodulatory drugs have been used empirically with the aim of regulating and suppressing the inflammatory reaction that leads to multi-organ failure and death [11] [22] , and, in a recent trial, the J o u r n a l P r e -p r o o f use of dexamethasone has been effective for those requiring invasive mechanical ventilation [29] .

At present, there are more than 50 trials under way with tocilizumab (clinicaltrials.gov) that will give clear information on the efficacy of this drug for severe Covid-19 disease. In the meantime, cohort studies, as ours, and clinical reports, are the only source of available information.

An initial report of 21 patients treated in China by Xu et al showed clinical improvement in all cases without deaths or adverse effects [17] . However, compare to our series, their patients were a median of nine years younger and also had a lower proportion of concomitant diseases, factors that might explain our higher fatality rate. In addition, the mean IL6 value of the patients in Xu´s series is like that of our group of survivors, but significantly lower than that of those who died in our study. It is possible that the blockage of the IL6R by TCZ might require higher doses in patients with higher serum IL6 levels. We could not evaluate this issue in our series as only a small proportion of our patients received two or more doses of TCZ.

A second cohort by Luo et al of 15 patients, eight of them also treated with steroids as most of our patients, showed a higher mortality rate (3/15, 20%) particularly in those patients with higher C reactive protein levels before TCZ administration [30] . Our data show similar results, showing a worst prognosis for those with higher CRP before and after tocilizumab treatment. However, other biomarkers such as IL6 levels and total lymphocyte count, and the amount of oxygen support needed are also key factors for the prognosis of this infection.

One of the larger cohort study published so far includes 179 subjects treated in different centres in Italy [31] and they used the same composite endpoint as ours, that is the need for intubation or death. Of note, both cohorts studied are similar in terms of age, comorbidities and severity of the disease, but not in the proportion of subjects treated with steroids, which is much higher in ours. Despite this, the proportion of patients achieving the primary endpoint (intubation or death) is similar in both series, 25,7 % in Guaraldi´s and 27,4 in ours. The proportion of new acute infections after TCZ was lower in our series (6,3 %) compare to theirs (13%), even with the use of steroids and cyclosporine in our group of patients. This might be related to a different and prolonged use of antibiotics in our series, or perhaps to a lack of recorded information due to the retrospective nature of the study. Of note, we did not observe any herpesvirus reactivation. In another large cohort study carried out in Italy [34] , with 196 subjects included, they observed an improvement in the results in non-intubated patients, treated early, as in our cohort, with tocilizumab, methylprednisolone or both. Several studies have shown improvements in median hospital stay or in respiratory and laboratory parameters [35, 36] . Even in patients who required intensive care unit support and mechanical ventilation, other authors have reported significant benefits when tocilizumab was added to the treatment of patients [37] [38] [39] . Despite these findings in several studies, the first study designed by the pharmaceutical company, the COVACTA trial, failed to meet its primary endpoint [40] . However, the company had recently announced [41] the efficacy of tocilizumab, with a reduction in the likelihood J o u r n a l P r e -p r o o f of needing mechanical ventilation in hospitalized patients with COVID-19-associated pneumonia, in the EMPACTA phase III clinical trial [42] . A detailed analysis of these data would be required after its publication.

The most significant result of our study, which should be evaluated in well-designed clinical trials, is that TCZ administration in severe but not critical cases is associated with a good prognosis, avoiding disease progression in 94% of cases, and only 6% requiring intubation due to progressive respiratory insufficiency. In contrast, we have observed that when the drug is given in more critical cases, with higher oxygen support needs, its value is less clear, at least in this group of cases treated with a single dose of TCZ and a multiple drug combinations including corticosteroids and cyclosporine. It is possible that higher or repeated TCZ doses might have added additional benefits. Mortality rates in hospitalised patients with SSP varies widely but it is around 15.1% -28% in Spanish, Italian and China studies [24, 32, 33] , significantly higher than that of our series of patient who received TCZ early in the course of the disease, when FiO2 requirement was below 0.5%.

Surrogate markers of macrophage activation, such as serum ferritin levels, interleukin-6 levels and high sensitivity C reactive protein changed after TCZ therapy, indicating a reduction of the inflammatory process. As expected, the median interleukin-6 levels increased 48 hours after tocilizumab, as have been shown in previous reports [30, 31] . Unfortunately, we do not have further data of these markers days or weeks after TCZ treatment. As expected, elevated inflammatory markers are associated with poor prognosis, despite TCZ use.

Most patients received only one dose of 400 mg tocilizumab, mainly because of shortage of the drug during the peak of the epidemic. Seventeen patients received two or more doses of the drug showing similar outcomes than those who received a single dose. These data suggest that even 400 mg of tocilizumab might be adequate for reducing the acute inflammatory process in severe cases, however, critical cases might require higher or repeated doses, an issue that we could not evaluate in our cohort.

The safety and tolerance of tocilizumab was good in previous studies of non SARS-CoV-2 patients [24, 25] . In our series, a small number of serious adverse events were reported and attributed by physicians to the drug. The acquisition of secondary nosocomial infections was detected in 13 patients (6·9%) being most of them lung or urinary tract infections of fungal or bacterial aetiology. However, all these cases had previously received systemic corticosteroids, cyclosporine and antibiotics, and most of them were admitted in the intensive care unit at the time the secondary infection was detected. These infections are probably due to the combination of these treatments and risk factors. This is notable because patients with rheumatoid arthritis or those receiving CAR-T cell therapy for cancer who are treated with long term use of tocilizumab are prone to infectious complications [25] [27, 28] but these seems not to be the case with single or limited TCZ administration.

Our study has several limitations, basically due to the retrospective collection of data and the absence of a control group. Firstly, the decision to administer tocilizumab was J o u r n a l P r e -p r o o f made by the medical team responsible for each patient, despite our treatment protocol. Therefore, the clinical status of patients and the timing of drug administration after the onset of Covid-19 symptoms were variable; initially it was indicated in very respiratory compromised patients and later it was prescribed much earlier, with lower FiO2 support, letting us study its efficacy in this situation. Secondly, the total amount of drug and number of doses that patients received were not uniform, due, as previously mentioned, to a shortage of the drug in the country during the peak of the epidemic. Thirdly, most patients had received previous and/or concomitant drugs, including systemic corticosteroids and hydroxychloroquine which have anti-inflammatory properties. Therefore, we could not properly assess the impact of these drugs on the overall response of patients treated with tocilizumab. Finally, survival rates would also have been influenced by the UCI committee decision whether a patient was eligible for intubation or not. Only large randomized clinical trials will be able to determine the impact of different immunomodulatory or anti-inflammatory drugs administered simultaneously.

In summary, our data support the use of TCZ in severe SARS-CoV-2 pneumonia, in combination with corticosteroids and other immunomodulatory drugs such as cyclosporine. When the respiratory compromise is still not very severe the survival rate is high (94%) and there are very limited side effects and secondary infections.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. We would first like to express our deepest gratitude for the patients and their families, who in a time of grief have contributed to the understanding of this disease. We are also grateful to the whole team of physicians and health personnel for their tireless, altruistic dedication, strength and effort during the current pandemics. Finally, we would like to acknowledge Dr. Frances Williams, for her invaluable role as English editor, Laura Cereceda as data manager and Drs Sánchez-Verde and Rodríguez de Lema for their contribution to graphical abstract.

Ethical approval This study was approved by the Medical Ethics Committee of the Fundación Jiménez Díaz University Hospital. Reference approval number: EO069-020. Figure 1 . Kaplan-Meiers curves for primary endpoint (need of invasive ventilation or death) in patients treated with tocilizumab. The blue line represents the group of patients who received tocilizumab when their oxygen support needs was low (FiO2 ≤0.5) and the green line represents the group of patients with higher oxygen support needs (FiO2 >0.5) at the time of tocilizumab administration. 

COVID-19 Map -Johns Hopkins Coronavirus Resource Center n

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Chloroquine for the 2019 novel coronavirus SARS-CoV-2

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Cytokine storms in infectious diseases

Tocilizumab in rheumatoid arthritis: A meta-analysis of efficacy and selected clinical conundrums

Pathogenic human coronavirus infections: causes and consequences of cytokine storm and immunopathology

Immunotherapeutic implications of IL-6 blockade for cytokine storm

Cytokine release syndrome

Effective Treatment of Severe COVID-19 Patients with Tocilizumab

Off-label Use of Tocilizumab in Patients with SARS-CoV-2 Infection

Tocilizumab in COVID-19 Pneumonia (TOCIVID-19) -Full Text View -ClinicalTrials

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J o u r n a l P r e -p r o o f

 Table 3 . Clinical, Laboratory, Imaging Data and Outcomes of Patients with Severe SARS-CoV-2 Pneumonia Treated with Tocilizumab.

Before After p Oxygen-support category -no.(%) 7 days after tocilizumab -FiO2 -0.21% (Ambient air) 
